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311World J Emerg Med, Vol 4, No 4, 2013

Acute hyperlipidemic pancreatitis in a pregnant woman

Ying Hang, Yi Chen, Li-xiong Lu, Chang-qing Zhu

 Emergency Department, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China

Corresponding Author: Chang-qing Zhu, Email: zhucq1965@126.com

Case Report

© 2013 World Journal of Emergency Medicine

BACKGROUND: Acute pancreatitis is a serious complication during pregnancy, however the

incidence of hyperlipidemia induced by pancreatitis is lower.

METHODS: We treated a pregnant woman with hypertriglyceridemia-associated acute

gestational pancreatitis who simultaneously developed hypoxemic acute respiratory failure (ARF).RESULTS: The woman was successfully treated through noninvasive positive pressure

ventilation (NPPV), emergent caesarean delivery, drainage of chylous ascites, and peritoneal

lavage.

CONCLUSION: The signs and symptoms of ARF were greatly improved in this patient after

NPPV and conventional therapies. Early NPPV may be related to good prognosis of the disease.

KEY WORDS: Hyperlipidemia; Pancreatitis; Pregnancy

World J Emerg Med 2013;4(4):311–313

DOI: 10.5847/ wjem.j.1920–8642.2013.04.013

INTRODUCTIONPancreatitis in pregnancy remains a rare event, and is

often associated with gallstone disease. Hyperlipidemic

gestational pancreatitis usually occurs in women with a

 preexisting abnormality of lipid metabolism.[1]

 We treated

a pregnant woman with acute pancreatitis who had been

 previously healthy with no history of cholelithiasis,

alcohol, inherited diseases, diabetes, nongestational

hyperlipidemia or drug abuse. We also reviewed the

literature about hyperlipidemic pancreatitis.

CASE REPORTA pregnant woman with acute pancreatitis caused

 by hyperlipidemia, aged 31 years, G2P0, was admitted

to our emergency department. On admission, she

complained of severe abdominal pain complicated

 by nausea and vomiting for one day in her 27-week

gestation. She was previously healthy with no history

of cholelithiasis, alcohol, inherited diseases, diabetes,

nongestational hyperlipidemia or drug abuse. Her

 body mass index was 22 kg /m 2 before pregnancy.

On admission, her body temperature was 36.8 °C,

 blood pressure 120/70 mmHg, heart ra te 120 bpm,

and respiration 20 bpm. Physical examination showed

harsh breath sounds and subxiphoid tenderness without

Grey Turner's or Cullen's sign. Laboratory examination

revealed amylase was 178 U/L, white blood cell count

7.9×109/L, hemoglobin 126 g/L, neutrophil 70%, HCT

0.39, platelets 106×109/L, CRP 148 mg/L, calcium 1.87

mmol/L, and blood glucose 7.2 mmol/L. At the same

time, arterial blood gas was pH 7.43, PCO2 41 mmHg,

PO2 78 mmHg, SaO2 96%, and HCO3 27 mmol/L. Renal

function was normal and blood sample was milky.

Triglyceride was 29.05 mmol/L and cholesterol was

18.05 mmol/L. The diagnosis of acute pancreatitis was

confirmed by computed tomography (Figure 1).

Abdominal pain was not relieved after the treatment

of abrosia, intravenous nutritional support, hydration,

lipid lowering agent, and gemfibrozil. The next day, the

 patient presented dyspnea with tachypnea 45 bmp, non-

invasive finger blood oxygen saturation 86%, and heart

rate 130 bmp. D-dimer assay was normal. Chest X-ray

showed diffuse infiltration of the lung. Arterial blood

gas analysis disclosed severe hypoxemia with a PaO 2/

FiO2 ratio of 190. A diagnosis of acute respiratory failure

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312  World J Emerg Med, Vol 4, No 4, 2013 Hang et al 

was made and APACHE II score was 5. The patient was

transferred to ICU. After NPPV, SaO2 increased to above

90%, respiration decreased to 28 bmp, and heart rate

reduced to 102 bmp. Lipid panel evidently decreased on

the fifth day after hospitalization. However, fetal heart

rate showed decelerations later. An emergent cesarean

delivery was performed under spinal anesthesia, and a

male infant weighing 1 180 g was delivered successfully.

The first and fifth minute Apgar scores were 5 and 6

respectively. The infant was then transferred to NICU.

Unfortunately, the infant died of severe immaturity

after one week. Intraoperative findings included

collection of 750 mL milky peritoneal fluid. Marked

swelling and saponification of the greater omentum

and gastrointestinal wall were noted. Peritoneal lavage

with normal saline and abdominal duct drainage were

 performed. The operation was successful. Subsequently,

dyspnea was resolved. Two weeks after operation, serum

triglyceride and cholesterols almost returned to normal.

Two months later, abdominal ultrasound showed a

 pancreatic pseudocyst. One-year follow-up showed that

 plasma lipid levels were within the normal ranges and no

recurrence of acute pancreatitis was noted.

DISCUSSIONHyperlipidemia is a rare cause of pancreatitis.

[2,3] 

Severe hyperlipidemia is uncommon in pregnancy.

Patients usually have pre-existing genetic defects

or diseases that can compromise lipid metabolism.

However, only a few cases of non-genetic, non-familial,

 pregnancy-induced hypertriglyceridemia have been

reported.[4] The pathogenesis of acute hyperlipidemic

 pancreatitis in pregnancy is under research.

Severe hyperlipidemia may trigger acute pancreatitis

and lead to serious complications. In the present case, the

 patient developed hypoxemic ARF in early stage. Some

studies have indicated that hypoxemia is closely relatedto the prognosis of acute pancreatitis. UK guidelines

for the management of acute pancreatitis emphasize

that SaO2 should be kept over 95%. NPPV could relax

respiratory muscles, reduce oxygen consumption

and atelectasis, increase lung volume, and alleviate

hypoxemia. Accordingly, patients with respiratory failure

caused by acute pancreatitis would benefit from NPPV.[5]

Severe hyperlipidemia may lead to acute pancreatitis

in pregnancy. Early diagnosis and prompt intervention

are proved to be live-saving. Treatment of acute

hyperlipidemic pancreatitis should be non-operative inaddition to appropriate timing, indications for surgery.

And operative procedures should follow the principles

of minimally invasive surgery.[6]

 Peritoneal lavage and

 post-operative abdominal duct drainage may be effective

in the treatment of such patients. In our case, 750 mL of

chylous ascites was drained from the abdominal cavity

during caesarean delivery. Few studies[7]

 have reported

 pr egna ncy- as soci at ed hype rl ip idemi c pa ncre at iti s

complicated with chylous ascites.

Therapeutic plasma exchange has been used in

the treatment of hyperlipidemic pancreatitis.[8]

 Doublefiltration plasmapheresis can be effectively and

safely applied in patients with acute hyperlipidemic

 pancreatitis.[9]

 Early plasmapheresis or lipid apheresis

can effectively reduce serum triglyceride, inhibit

disease progression, and prevent the recurrence of

hyperlipidemic pancreatitis, but it has risk of acute

coronary events.[10,11]

 Batashki et al[12]

  reported that

intubation with artificial pulmonary ventilation and high

volume continuous veno-venous hemofiltration (HV

CVVH) should be performed because of the development

of polyorgan insufficiency and ARDS. In our case, signsand symptoms of ARF were greatly improved after

 NPPV and conventional therapies, thus creating the

opportunity to perform caesarean delivery when fetal

distress occurred. We think that early NPPV is closely

related to good prognosis.

Funding: None.

Ethical approval: Not needed.

Conflicts of interest: None.

Contributors: Hang Y proposed the study, analyzed the data andwrote the first draft. All authors contributed to the design and

interpretation of the study and to further drafts.

Figure 1. CT showing an extensively swollen pancreas, disappearanceof the space among peripancreatic adipose tissues and thickening of theanterior fascia of the kidney on the left side.

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REFERENCES1 Crisan LS, Steidl ET, Rivera-Alsina ME. Acute hyperlipidemic

 pancreatitis in pregnancy. Am J Obstet Gynecol 2008; 198:

e57–59.

2 Serpytis M, Karosas V, Tamosauskas R, Dementaviciene J,

Strupas K, Sileikis A, et al. Hypertriglyceridemia-induced acute

 pancreatitis in pregnancy. JOP 2012; 13: 677–680.

3 Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J

Clin Gastroenterol 2003; 36: 54–62.

4 Eskandar O, Eckford S, Roberts TL. Severe, gestational, non-

familial, non-genetic hypertriglyceridemia. J Obstet Gynaecol

Res 2007; 33: 186–189.

5 Song RR, Qiu YP, Chen YJ, Ji Y. Application of fiberoptic

 bronchscopy in patients with acute exacerbations of chronic

obstructive pulmonary disease during sequential weaning of

invasive-noninvasive mechanical ventilation. World J Emerg

Med 2012; 3: 29–34.

6 Sun B, Xu DS, Jiang HC, Tai S, Cui YF, Xu J, et al. Study oncombined therapy of hyperlipidemic severe acute pancreatitis.

Zhonghua Wai Ke Za Zhi 2007; 45: 733–735.

7 Chuang SC, Lee KT, Wang SN, Kuo KK, Chen JS.

Hypertriglyceridemia-associated acute pancreatitis with chylous

ascites in pregnancy. J Formos Med Assoc 2006; 105: 583–587.

8 Al-Humoud H, Alhumoud E, Al-Hilali N. Therapeutic plasma

exchange for acute hyperlipidemic pancreatitis: a case series.

Ther Apher Dial 2008; 12: 202–204.

9 Zhang G, Feng J, Xu QP, Huang HY. Double filtrat ion

 plasmapheresis in treatment of hyperlipidemic acute pancreatitis.

Zhejiang Da Xue Xue Bao Yi Xue Ban 2008; 37: 93–96.

10 Kyriakidis AV, Raitsiou B, Sakagianni A, Harisopoulou V,

Pyrgioti M, Panagopoulou A, et al. Management of acute severe

hyperlipidemic pancreatitis. Digestion 2006; 73: 259–264.

11 Kadikoylu G, Yavasoglu I, Bolaman Z. Plasma exchange in

severe hypertriglyceridemia a clinical study. Transfus Apher Sci

2006; 34: 253–257.

12 Batashki I, Milchev N, Uchikova E, Pekhlivanov B, Chifligarov

K, Uchikov A. Hyperlipidemic pancreatitis during pregnancy-a

case report. Akush Ginekol (Sofiia) 2006; 45 Suppl 1: 41–43.

Received May 11, 2013

 Accepted after revision September 20, 2013